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Planning for Healthy Living: the Next Challenge
Suzanne H. Crowhurst Lennard, Ph.D. (Arch.)
It is common today to talk about health only in terms of physical health. The “Active Living” program is often considered the solution to all health problems. In fact, even as cities enact “Active Living” programs to solve obesity, they discover the programs are ineffectual if the society is fragmented or the individual is marginalized. Social health is the foundation for physical health. This has serious implications for planning and urban design. A healthy city must have a healthy "social immune system".
Humans are social beings. Contact with family, friends and social circles is not just pleasurable, it is essential. An individual’s very sense of self is shaped and maintained through social life. The quality and quantity of social interaction and sense of belonging strongly influence physical and mental health (Baum and Ziersch 2003; Warr et al. 2007; Poortinga et al. 2007; Cohen et al. 2008; Echeverría et al. 2008; Beard et al. 2009; Dahl and Malmberg-Heimonen 2010).
Suburban environments do not provide sufficient opportunity for positive social life. We began to see evidence of this in ‘50s when depression became common among stay-at-home housewives and valium was thought to be the solution. Now we see it in the prevalence of psychological and social problems suffered by children, youth and elders that echo the symptoms of social isolation. Dangerous, fragmented inner city neighborhoods exhibit similar symptoms of ill health, related to the isolation of individuals in the fragmented built, and social fabric.
High-rise housing has been associated with greater rates of juvenile delinquency (Gillis, 1974), greater feelings of alienation (McCarthy D & Saegert, S. 1978), and more depression among young mothers (Richman, 1974). Gifford (2007) provides a comprehensive review of the literature on the effects of high rise housing on children, mental health, social behavior, crime, and suicide. As he summarizes, “the literature suggests that high-rises are less satisfactory than other housing forms for most people, that they are not optimal for children, that social relations are more impersonal and helping behavior is less than in other housing forms, that crime and fear of crime are greater, and that they may independently account for some suicides.”
Harlow (1964) dramatically raised awareness of the effects of social isolation. Rhesus monkeys, isolated at birth, developed signs of depression, violence and self-immolation. They developed “autistic” behavior, “repetitive stereotyped movements, detachment from the environment, hostility directed outwardly toward others and inwardly toward the animal's own body, and inability to form adequate social or heterosexual attachments to others when such opportunities are provided in preadolescence, adolescence, or adulthood” (Cross and Harlow, 1965).
Partial social isolation, where they could see and hear other monkeys but had no physical contact, resulted in blank staring, repetitive circling, and self-mutilation. They were helpless in a social environment because they had not developed social skills. When placed with normally raised monkeys they were shunned, bullied, or became violent. Many never learned the social skills necessary to become integrated.
Human beings react in similar ways. Indeed, one of the most serious punishments we can inflict is solitary confinement, which can result in serious existential crisis (Grassian, 1993), and deterioration of mental (Kernes, 1998) and physical health. Prison studies have shown that solitary confinement leads to physical illness, mental anguish, violence, terror, even suicide (Grassian, 1993). Over time, symptoms experienced by isolated prisoners are “likely to mature into either homicidal or suicidal behaviour” (McCreary, 1961).
Breakdown in community social life has particularly serious health consequences for elders. An increased risk of ill health and death exists “among persons with a low quantity, and sometimes low quality, social relationships.” (House et al, 1988;) According to Cohen (1988) and Berkman (1995), lack of social ties or social networks predicts mortality from almost every cause of death. According to Berkman et al (2000), “The power of these measures to predict health outcomes is indisputable”.
With insufficient or negative social interaction elders especially are vulnerable to suffer loneliness, low self-esteem, social anxiety and depression (House et al, 1988; Hawe and Shiell, 2000; Cohen-Mansfield and Parpura-Gill, 2007). Bellah et al (1985) proposed that without a meaningful sense of connectedness to others, and without a clear involvement in a meaningful social fabric, individuality and life itself lose meaning. As Durkheim (1897; 1951) proposed, the underlying reason for suicide is lack of social integration to a supportive group.
In early studies of schizophrenia, Faris (1934) observed that insufficient and unsatisfactory social interaction can lead to further withdrawal. One study found support for the hypothesis that the “shut-in” or “seclusive” personality, “generally considered to be the basis of schizophrenia, may be the result of an extended period of ‘cultural isolation’, that is, separation from intimate and sympathetic social contact”. He adds that “seclusiveness is frequently the last stage of a process that began with exclusion or isolation which was not the choice of the patient” (p. 159).
Social isolation and neighborhood fragmentation proved an involuntary death sentence for hundreds of elderly during the 1999 Chicago heat wave. Klinenberg (2003) found that disproportionately high numbers of elderly deaths occurred in neighborhoods “dominated by boarded or dilapidated buildings, rickety fast-food joints, closed stores with faded signs, and open lots” filled with “tall grass and weeds, broken glass and illegally dumped refuse…” In these areas, elders lived in isolation, afraid to go onto the street, and far from people or places that could help them survive the heatwave.
In an adjacent, equally poor neighborhood, elders were protected in the heatwave. “First, the action in and relative security of the local streets pulled older people into public places, where contacts could help them get assistance if they needed it. Second, the array of stores, banks and other commercial centers in the area provided senior with safe, air-conditioned places where they could get relief from the heat. Seniors felt more comfortable in and are more likely to go to these places, which they visit as part of their regular social routines, than the official cooling centers that the city established during the heatwave…. The robust public life of the region draws all but the most infirm residents out of their homes, promoting social interaction, network ties, and healthy behavior.”
Sprawl has created a world in which children have fewer friends than ever before. The absence of accessible, lively public places where children can meet, forbidden to play on the street, and under strict instructions to stay in the house, teens spend more time alone – 3 ½ hours per day – than with family or friends (Eberstadt, 1999). With long work hours, long commutes, and long drives to run simple errands, parents leave kids “home alone”.
Most time alone is spent interacting not with a living world, but with technology, where children are exposed to and shaped by the dysfunctional and violent role models presented in the “virtual” world. (Lennard and Crowhurst Lennard, 2000). As Hochschild (1997) reports, “children who were home alone for eleven or more hours a week were three times more likely than other children to abuse alcohol, tobacco or marijuana.”
“Spending extensive time alone can be stressful. Young people report having lower self esteem, being less happy, enjoying what they are doing less, and feeling less active when they are alone.” In considering the social consequences of “children raising themselves”, Eberstadt comments, “One does not have to read Durkheim to see the isolation writ large in these numbers, or to speculate about the effects of such endemic isolation on a chronically melancholic adolescent temperament” Eberstadt (2001).
When children lack social contact, they do not learn the social skills needed to maintain health and well-being throughout life, and to strengthen resilience in avoiding social pathology. Positive social interactions, membership in a social support system and a sense of belonging protect and promote good health (House et al, 1988).
In the US today, children are not experiencing the community social support they require for healthy development and success in life. Moreover, all aspects of child development benefit from positive social contexts within which this learning is embedded. Too many children lack the experience of belonging to a supportive complete community and will therefore not be able to pass this knowledge on to the next generation (Bronfenbrenner, 1979).
Given the lack of real social networks, it is no surprise that children and adolescents find difficulty in social situations. Shyness is increasingly treated as a medical problem, termed “Social Anxiety Syndrome”, for which medications are often prescribed – though these occasionally lead to violence and suicide.
Lynn Henderson (Henderson and Zimbardo, accessed 2008), Director of the Palo Alto Shyness Clinic, maintains that “this rise in shyness is accompanied by spreading social isolation within a cultural context of indifference to others and a lowered priority given to being sociable, or in learning the complex network of skills necessary to be socially competent.” She proposes this may be “a warning signal of a public health danger that appears to be heading toward epidemic proportions.” Lack of real life social skills may also lead young people desperate for some form of social contact into inappropriate, predatory or damaging exchanges in technologically mediated social networks.
Depression among adolescents
In the US, 8.3 percent of adolescents suffer from depression (Birmaher et al, 1996). Since young people with limited social skills do not know how to solve problems through negotiation and discussion, they may act self-destructively, particularly if they are being bullied and made to feel worthless. Suicide is the fourth leading cause of death for children aged 10-14 (Friday, 1995). 60% of high school students reported having considered suicide, 9% reported having tried (AAP, accessed 2011).
Combative youth lacking social skills to resolve differences, and needing to increase their self-esteem may be violent towards others, especially towards those who are different and who lack social skills to defend themselves. A recent study showed that 29 percent of the students who responded to a survey had been involved in some aspect of bullying (NICHD, accessed 2011). “People who were bullied as children are more likely to suffer from depression and low self esteem, well into adulthood, and the bullies themselves are more likely to engage in criminal behavior later in life” (Alexander, accessed 2011). School shootings are committed by “adolescent outcasts” (Eberstadt, 2001). Gang warfare provides youth a sense of membership, and a feeling that their existence is of significance to others. Homicide was the 2nd leading cause of death for young people aged 10 to 24 years old (CDC, 2010b).
Stanley Greenspan (1997) warned, “as children become more alienated from the lives of others… we can expect to see increasing levels of violence and extremism and less collaboration and empathy.” He emphasizes that children need “to grow up amid a network of close interactions with adults.” Until recently, he observed, “even in cities, families spent their days mostly within the compass of neighborhoods one could easily traverse on foot… Ordinary life thus naturally and routinely provided the conditions that the complex human nervous system needs to fulfill its potential.”
It has been suggested that “In Western societies, we have perhaps lost sight of the crucial role of social support in preparing children for their adult roles. Families are often fragmented and socially isolated, relationships transient, and the roles of parents, schools, and other institutions unclear and discontinuous. … there are many Western children and adolescents for whom the discontinuities are defeating, and who fail to make the transition from childhood to competent adulthood for lack of continuous and coherent social support.” (Tietjen, 1989)
Social immune system
Positive social interactions, membership in a social support system and a sense of belonging protect and promote good health. It has been found that social capital protects against negative health outcomes and mortality (Berkman & Syme, 1979; House et al 1988). For people of all ages, physical and mental health is improved by face to face interaction and membership in a community (Resnick et al, 1997). It is through frequent informal face-to-face interaction that social ties develop (Greenbaum, 1982).
Circles of friends and familiars form a “social immune system” to buffer stress, improve coping, and protect health. Social support prevents isolation, improves psychological well-being through being valued, receiving signs of love, and knowledge that help is there if needed. Integration in a social network produces positive psychological states (Cohen et al, 2000): it fosters self-esteem, self-assurance, sense of security and well-being (Berkman and Glass, 2000). Social circles “maintain, protect, promote and restore health” (Nestmann and Hurrelmann, 1994).
Kawachi and Berkman (2000) conceptualized three pathways through which social capital could affect health at the neighborhood level: access to services and amenities, psychosocial processes, and health-related behaviors. The significant psychosocial processes were refined by Berkman et al (2000) as: a) Social support, meaning emotional, instrumental and informational support; b) Social influence, i.e. the general consensus within a social network about healthy behavior, values and norms, i.e what Erickson (1988) called “normative guidance”; and c) Social engagement: “Getting together with friends, attending social functions, participating in occupational or social roles, group recreation, church attendance” etc. These ties give meaning to an individual’s life and a sense of being attached to one’s community.
It is through frequent informal face-to-face interaction that social ties develop (Greenbaum, 1982). Frequent meetings and greetings in the public realm allow people to become familiar with one another, to “learn one another’s stories” (Berry, 1994) which builds trust and caring. Higher levels of trust in a community are associated with lower rates of most major causes of death, including heart disease, cancers, infant mortality, and violent deaths, including homicide (Kawachi et al, 1997). Kawachi and Berkman (2001) analyzed the varied mechanisms by which social ties contribute to mental health.
At the neighborhood level, Lochner and colleagues found that social capital, as measured by reciprocity, trust, and civic participation, was associated with lower neighborhood mortality rates after adjusting for neighborhood material deprivation (Lochner, Kawachi, Brennan, & Buka, 2003).
Mental health improves when people feel less lonely or isolated (Beard et al. 2009; Maas et al. 2009a; Maas et al. 2009b; Odgers et al. 2009; Berry and Welsh 2010; Yang and Matthews 2010). Children as well as adults need to feel they “belong” within a community (McMillan and Chavis, 1986).
Children and youth
Good social skills, and the ability to take pleasure in social interaction are fundamental to maintaining good health, to all aspects of child development, and to achieving success and well-being later in life (Levine, 2002). Social skills do not develop automatically. They are learned in the community social contexts in which children are raised. They learn this through observation of how adults around them behave, and by reenactment of the same behavior.
Children must learn the skills of making friends, and of maintaining friendships. They must learn how to interact with people very different from themselves – involving the ability to understand a person’s character, and to distinguish between “friend” and “foe”. “The more varied and reciprocal these interactions, the richer will be the individual’s self-image and the more comprehensive her consciousness” (Greenspan, 1997).
For adolescents, supportive relationships with adults in the community are particularly valuable in preventing psychological harm from stressful life experiences that place a burden on the mental and physical health of children and youth (Rutter, 1983). Social support helps children to develop resilience and to successfully cope with stress (Garmezy, 1983; Werner and Smith, 1982). Youth in dysfunctional settings who have one good relationship are at lower risk of psychiatric disorder (Rutter and Giller, 1983). When comparing communities with high rates of healthy youth to communities with low rates, the healthy youth were found to be better connected to a variety of social systems (Blyth and Leffert, 1995). Leffert et al (1998) emphasize that “young people need multiple constructive experiences and supportive, caring relationships across the many contexts in which they interact” and the effects of these interactions are cumulative in preventing adolescent risk behavior.
For adolescents, supportive relationships with adults in the community are particularly valuable in preventing psychological harm. This is especially true for vulnerable adolescents with few personal assets (Blyth and Leffert, 1995). African American youth, especially adolescent girls, who have neighbors who look out for them are less likely to report feeling depressed than adolescents in less supportive neighborhoods (Stevenson, 1998). This is also true for adolescents in high risk neighborhoods.
Adults & elders
The opportunity for social interaction, companionship, people-watching, and a “friendly neighborhood” were reported as reasons why adults chose to walk in their neighborhood, whether to shop, run errands, recreate, or simply to get exercise (Ball et al, 2001; Giles-Corti and Donovan, 2002; Booth et al, 2000; Ståhl et al, 2001; Humpel et al, 2002). Indeed, as Ståhl reported in a study of adults across six countries, “The social environment was the strongest predictor of being physically active.” More active adolescents considered that the social environment and neighbors with recreational facilities are associated with higher levels of physical activity (Mota et al, 2005). Social support for physical activity among adults (Eyler et al, 1999; Castro et al, 1999; Corneya et al, 2000) and among college students (Leslie et al, 1999) is a strong correlate of physical activity.
Social capital at the neighborhood level, as measured by reciprocity, trust, and civic participation, is associated with lower neighborhood mortality rates (Lochner et al, 2004). As one interviewee recorded by Altschuler et al (2004) reported: “I feel that my neighborhood contribute(s) to my health, and it does so in many ways. (If) something, an accident happens and I break my leg in my house I know my neighbors will come to my aid. (But) I think that over time even a greater impact is having a sense of belonging and a sense of neighbors that I trust around me helps reduce anxiety and it’s good for my mental well being.”
Numerous recent studies have supported the thesis that a sense of belonging is an influential determinant of mental and physical health (Wilkinson, 1996, Hawe and Shiell, 2000; Baum and Ziersch, 2003; Ogunseitan, 2005; Warr et al., 2007; Poortinga et al., 2007; Cohen et al., 2008; Echeverría et al., 2008; Beard et al., 2009; Dahl and Malmberg-Heimonen, 2010).
Communities with high collective efficacy, i.e. “mutual trust and a willingness to intervene in the supervision of children and the maintenance of public order” (Sampson et al, 1997) generally experience low homicide and violence rates and low levels of physical and social disorder, while neighborhoods with low collective efficacy suffer high rates of violence and significant physical and social disorder (Earls, 1998). A functioning neighborhood community in which people take some responsibility for others helps children to develop positive social skills, even in neighborhoods with problems of high vandalism and crime (Earls, 2005), and it helps elders to continue to live a normal, healthy life in their community.
Peter Benson (2006), President of the Search Institute observed, “Instead of embedding our children in webs of sustained relationships, we segregate them from the wisdom and experience of adults, raising them in neighborhoods, institutions, and communities where few know their names. Instead of celebrating them as gifts of energy, passion, and hope, we view them with suspicion in public places and places of commerce and deny them meaningful roles in community and civic life.”
He recognized that the key problem that thwarts these efforts is that our physical environment does not support community, and adds, “If there were only one thing we could do to alter the course of socialization for American youth, it would be to reconstruct our towns and cities as intergenerational communities. Cross-generational contacts would be frequent and natural.”
Healthy Urban Fabric
To support a healthy immune system, we must rebuild the compact, mixed use built urban fabric characteristic of traditional towns. Here, people’s paths cross in multiple situations – on the way to work or school, at the market or running errands, at a “Third Place” or relaxing -- and in different social contexts – alone, with family members, friends or business associates. Community members' normal everyday lives overlap. Meetings may lead to introductions that expand social networks. This promotes resilience in the community's social immune system.
A significantly greater sense of community is found in mixed use neighborhoods (Nasar and Julian, 1995; Leyden, 2003, Lund, 2002). The availability of local shops and restaurants is seen by residents to be health promoting. “The provision of decent housing, safe playing areas, transport, green spaces, street lighting, street cleaning, schools, shops, banks, etc. impacts upon participation in that their presence facilitates social interaction and a ‘feel good’ sense about a place.” (Baum and Palmer, 2002). Mehta (2007) emphasized additional factors supportive of social interaction, such as hospitable commercial streets, mixed use streets with shops and restaurants , wide sidewalks and a personalized public realm. As Cozens and Hillier (2008) stressed, it requires a great many more factors than simple street layout to create a neighborhood that fosters social interaction.
Frank et al (2004) showed that the greater the degree of land use mix, the less time adults spent in cars and the lower the rate of obesity. Small city blocks, street connectivity, mixed land uses and proximity of shops are associated with an increase of walking (Cervero and Duncan, 2003; Duncan and Mummery, 2004; Frank et al, 2005).
Dangerous settings discourage individuals from building social ties (Evans, 2006). Public places must be designed to feel safe as well as to prevent criminal activity. This is achieved by encouraging a sense of ownership, ensuring eyes on the street, maintaining active use of the space and surrounding buildings, and controlling access (Crowe, 2000). Even a courtyard in an apartment building can provide some support for a significantly greater development of community among residents than exists in an apartment building without a courtyard (Nasar and Julian, 1995).
Style of housing and land use patterns have been found to affect social networks (Cattell, 2001) and thereby to affect health (Macintyre et al., 1993; Macintyre and Ellaway, 1998; Macintyre and Ellaway, 1999; Macintyre and Ellaway, 2000). Their data showed a strong link between social interactions and ‘local opportunity structures’—‘socially constructed and socially patterned features of the physical and social environment which may promote health either directly or indirectly through the possibilities they provide for people to live healthy lives’ (Macintyre and Ellaway, 2000), p. 343]. They argue that: “Social capital is often seen to be inherent in social interactions and social relations, but we would like to suggest that these might be facilitated by local opportunity structures, often of a mundane kind.” (Ibid, p. 169]
Williams and Pocock (2010) emphasize that the more informal “third places” there are in a neighborhood, the greater the opportunity for serendipitous social interaction that can lead to caring relationships and social capital. They also stress that people of different age groups need different kinds of places that facilitate unplanned meetings. Some third places such as cafes and bars cater to specific population groups (adult drinkers, those who can afford to eat there) and some exclude children. Pendola and Gen (2008) demonstrated that neighborhoods with main streets have a significantly higher sense of community than exists in high density neighborhoods of suburban style neighborhoods without a main street. Of still greater value for community social life that includes children and youth are central public plazas open to all.
Public space design
The key element is the public realm, specifically, the availability of community squares that support positive face-to-face social interaction between young and old. The intrinsic value of personal social contact consists in the boost to self-esteem, pleasure, and sense of well-being associated with eye contact, being acknowledged and confirmed by another human being, emotional reciprocity, an “authentic” encounter, and knowing others are concerned and interested in one’s well-being (Buber, 1965). “The unavowed secret of man” stressed Buber (1967) “is that he wants to be confirmed in his being and his existence by his fellow men and that he wishes them to make it possible for him to confirm them… The architects must be set the task of also building for human contact, building surroundings that invite meeting and centers that shape meeting.”
When located at the heart of a mixed-use neighborhood, with a farmers market, surrounded by shops serving daily needs, and a residential population overlooking the square, these places are powerful catalysts in building community, and the social support systems that protect health (Crowhurst Lennard and Lennard, 2008). Successful plazas are places people need to visit, or pass through on a frequent basis to go shopping, to go to the market, or to go to work. Only this level of use by a local community can generate the high degree of community life required to develop inclusive community ties.
In the Netherlands, where recent declining health levels have been linked to decrease in social contacts, public health researchers have called for “a more developed and detailed governmental policy to promote community” (De Vos, 2003). In North America, I would suggest, we would be wise to follow suit.
If we want to improve physical and mental health, reduce social pathology, and strengthen community “social immune systems”, then we must rebuild our sprawling suburbs and inner city neighborhoods so that they support the development of face-to-face interaction and community in traffic-calmed streets and lively neighborhood squares.
All the elements necessary to successfully foster social life and community are outlined in the IMCL “Principles of True Urbanism” (Crowhurst Lennard and Lennard, 2004) and discussed in IMCL publications such as Livable Cities Observed (Crowhurst Lennard and Lennard, 2000) and Genius of the European Square (Crowhurst Lennard and Lennard, 2008).
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